11/2/2016

Cardiac Rehabilitation: A life changing therapy Andrew Boerkircher, DO Cardiovascular Fellow Gill Heart Institute University of Kentucky

Post myocardial infarction, which therapy was shown to have a 7% reduction in mortality at 5 weeks? 1) Aspirin 2) ACE inhibitors 3) Beta blockers 4) Statins 5) Cardiac Rehab

Post myocardial infarction, which therapy was shown to have a 23% reduction in vascular mortality at 35 days?

1) Aspirin 2) ACE inhibitors 3) Beta blockers 4) Statins 5) Cardiac Rehab

Goals of this conference: • • • • •

Define cardiac rehab Discuss phases of rehab Define eligibility Discuss benefits of rehab Express the importance of rehab

Post myocardial infarction, which therapy was shown to have a 11% reduction in cardiovascular mortality at 1 year?

1) Aspirin 2) ACE inhibitors 3) Beta blockers 4) Statins 5) Cardiac Rehab

Post myocardial infarction, which therapy was shown to have a 25% reduction in cardiovascular mortality at 5 years?

1) Aspirin 2) ACE inhibitors 3) Beta blockers 4) Statins 5) Cardiac Rehab

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Post myocardial infarction, which therapy was shown to have a 26% reduction in cardiovascular mortality at 1 year?

1) Aspirin 2) ACE inhibitors 3) Beta blockers 4) Statins 5) Cardiac Rehab

Leading Causes of Death in the US (1998-2008) Males Females 386,436

450

401,495

400 350

296,763

270,865

300 250 200 150 100 50 0

Go AS. Circulation 2012

Deaths from Cardiovascular Disease

CVD Mortality, 1979-2007

Death rates from CVD have decreased over the last 30 years

Roger VL. Circulation 2011

Rogers, Circulation, 2010

Why? • 44% of the decline attributable to changes in risk factors • Lower total cholesterol--24% • Lower systolic blood pressure--20% • Lower smoking prevalence--12% • Decreased physical inactivity—5% • Increased number of death from increased BMI 8%

Rogers, Circulation, 2010

Why? • 47% of the decline attributable to treatment • Secondary prevention post MI/revascularization--11% • Initial therapy for AMI--10% • Treatment of HF--9% • Revascularization for chronic angina--5% • Other therapies including antihypertensives and lipid-lowering primary prevention therapies--12%

and DM 10%

Rogers, Circulation, 2010

Rogers, Circulation, 2010

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Cardiac Rehab Defined Comprehensive LIFESTYLE MODIFICATION PROGRAM consisting of EXERCISE AND EDUCATION through collaboration from an interdisciplinary team

What is Cardiac Rehab?

https://youtu.be/SGGKHqYEMqc?t=122 https://youtu.be/XfQDFESD3V4?t=103

Myocardial infarction first described

2006

1995

1986

1970

1960

Patients wereOutpatient allowed 3-5 rehab minutes of walking twice programs began to th week daily during the 4appear post-MI 1955

1950

Medical Director (Dr. Bhalla) Exercise Physiologists Exercise Specialist RNs Dietitians Tobacco Treatment Specialist Pharmacists Emotional health counseling (outside referral)

1912

• • • • • • • •

1940

How did we get here?…

Interdisciplinary Staff

Patients were confined to He believed that “a the bed for 2 months in normal person should Paul Dudley Wenger and The Clinical guideline on “Chairthat therapy” “Early Hospital stay American US hours Center for Medicare fears physical activity exercise seven White consults “Cardiac by described ambulation” after MI colleagues Association ofRehab”aissued and Medicaid Services wouldbegins lead to the on President publish rehab the US Department of If you cannotthat cardiac decreased to 3 week.Cardiovascular concluded Health and Human formation ofEisenhower aneurysms, weeks protocols and Pulmonary exercise rehab an hour is “reasonable after his MI Services, Agency for and Rehabilitation heart failure, cardiac necessary” after certain everyday,(AACVP) make up the Healthcare Policy and diagnoses rupture, or sudden death Research difference on the formed weekend”

Pashkow, FJ. Clinical Cardiac Rehabilitation

CLASS 1 INDICATION 1) Myocardial infarction (NSTEMI or STEMI within past 12 months) 2) PCI (within past 12 months)

Who is eligible?

3) Cardiac surgery (CABG, valve replacement, transplant) 4) Chronic stable heart failure (EF < 35% and NYHA class II-IV symptoms) 5) Chronic stable angina 6) PVD (not covered by insurance)

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Exercise is just one piece the puzzle!

Having fun is part of healing!

Phase I

Phases of Cardiac Rehab

• Usually in the inpatient setting • Goals to increase mobility, flexibility, endurance, and balance. • Early mobilization post-op can reduce ICU stays up to 20% and floor stays up to 40% saving an estimated $1.5 million per year. Corcoran JR1, Herbsman JM1, Bushnik T2, Van Lew S1, Stolfi A1, Parkin K1, McKenzie A3, Hall GW4, Joseph W5, Whiteson J6, Flanagan SR7. Early Rehabilitation in the Medical and Surgical Intensive Care Units for Patients With and Without Mechanical Ventilation: An Interprofessional Performance Improvement Project. PM R. 2016 Jun 23. pii: S1934-1482(16)30223-4. doi: 10.1016/j.pmrj.2016.06.015. [Epub ahead of print].

Phase II, Early Outpatient “Cardiac rehab” Initial Assessment / Plan Development 1. Exercise Eval – functional capacity (6 min walk) & balance

2. Nutrition Eval – BMI, lipids, eating habits 3. Psychosocial Eval – Screen for depression, anxiety, QOL, fears, concerns

4. Education Eval – Med review, BP, Ed level, etc. *The initial treatment plan & all 4 components are a mandatory requirement by Medicare and AACVPR for program certification

Phase II “Cardiac rehab” • Composed of aerobic exercise, strengthening exercises, flexibility, and balance exercises. • Exercise in a monitored setting. • Active communication with referring provider. *Insurance Covers, generally 24-36 visits, 2-3d/wk, 2-4 months *Can be repeated yearly for HFrEF or after each new PCI

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“Phase III” (Wellness Program) • • • •

Self-pay Education Supervised exercise Can attend indefinitely Pricing: 3 days/week for 30 days - $60 2 days/week for 30 days - $40

Why is referring Important?

Post-PCI, referral & enrollment in CR was considered on the same plane as the use of statins and ASA

Evidence for cardiac rehab

HFrEF • Reduced hospital admissions (RR 0.61) • Improved QOL (-5.8 pts on MLWHF) • No change in allcause mortality

Percutaneous Coronary Intervention ACC/AHA/SCAI/AMA–Convened PCPI/NCQA 2013 Performance Measures for Adults Undergoing Percutaneous Coronary Intervention

Taylor RS1, Sagar VA, Davies EJ, Briscoe S, Coats AJ, Dalal H, Lough F, Rees K, Singh S. Exercise-based rehabilitation for heart failure. Cochrane Database Syst Rev. 2014 Apr 27;(4):CD003331. doi: 10.1002/14651858.CD003331.pub4.

Exercise‐based cardiac rehabilitation for coronary heart disease • Reduced hospital admissions (RR 0.82) • Reduced CV mortality (RR 0.74) • No change in MI or repeat revascularization (PCI or CABG) • No change in all-cause mortality

Cochrane Database of Systematic Reviews. 5 JAN 2016 DOI: 10.1002/14651858.CD001800.pub3 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001800.pub3/full#CD001800-fig-0004.

No Randomized Controlled Data, but… • Between 1982 and 1998, 2019 people had an MI in Olmstead Co, Minnesota and 1821 of these survived to discharge • Of these, 55% participated in Cardiac Rehab: ♦ 38% of all women vs 67% of all men with MI ♦ Participation declined with increasing age ♦ Participation remained stable over the time span Witt BJ, Jacobsen SJ, Weston SA et al. Cardiac rehabilitation after myocardial infarction in the community. J Am Coll Cardiol. 2004 Sep 1;44(5):988-96.

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Cardiac Rehab in Olmstead County

Cumulative incidence of death by number of cardiac rehabilitation sessions attended.

Survival in the Participants and Non-participants of Cardiac Rehab 100

95%

% Survival

80

60

64%

40 No Rehab 20

Rehab

P